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Thien Thanh Dang-Vu, Rébecca Robillard, Charles M. Morin, Nadia Gosselin: Time to make safe insomnia treatments available to all
This article was originally published in The Gazette.
As sleep medicine researchers and clinicians, we are concerned about the lack of public reimbursement for the first recommended line of intervention.
We are writing in light of a recent publication by the Canadian Sleep Research Consortium on the prevalence of insomnia across the country, affecting one in six Canadians. This study highlights the widespread use of medications, alcohol and cannabis as sleep aids. This year, a Radio-Canada report — Cauchemar sur ordonnance — exposed the dangers of benzodiazepines, often prescribed for sleep.
Before resorting to medication, the first recommended line of intervention for insomnia is Cognitive Behavioural Therapy for Insomnia (CBT-I). Despite three decades of research demonstrating its effectiveness and the consensus among sleep experts, this treatment is still not available to the vast majority of Canadians suffering from insomnia. As sleep medicine researchers and clinicians, we are concerned about the lack of public reimbursement for effective and safe treatments for insomnia.
Insomnia involves difficulty falling or staying asleep and is considered a disorder when it occurs at least three nights per week for at least three months, with daytime fatigue or other impacts. Insomnia disorder (also called chronic insomnia) is widespread, affecting 16.3 per cent of the population, with significant consequences for physical and mental health. Its impact on work and productivity is also well-documented, costing Canadians $1.9 billion every year.
Despite these considerable impacts, access to effective and safe treatment remains a major challenge, largely due to the absence of public reimbursement. One of the main consequences of this unmet need is the excessive reliance on non-recommended treatments such as sedatives taken off-label or those with limited indications like benzodiazepines.
Benzodiazepines carry numerous risks, including dependence, cognitive decline, road accidents and falls. This is why the American Geriatrics Society advises against their use in the elderly, regardless of the duration of treatment, and their chronic use is discouraged at any age.
However, benzodiazepines remain the only options covered by Quebec’s public health insurance (RAMQ) for chronic insomnia patients, which is incompatible with the frequent need for long-term insomnia treatment. In Quebec, the treatment of sleep apnea, often associated with insomnia, is also not covered by the public system, adding further strain on those suffering from sleep disorders.
And what about the insomnia that affects over 30 per cent of children and adolescents in Canada? Its impact on school performance and physical and mental health is disastrous, not to mention the psychosocial toll on the entire family. Health Canada does not endorse any pharmacological intervention for pediatric insomnia, and access to behavioural approaches is nearly non-existent.
The Collège des médecins du Québec recently launched a monitoring program for the safe use of benzodiazepines, aimed at protecting the public through increased surveillance of benzodiazepine prescribers. However, there are no alternatives to benzodiazepines on RAMQ’s list of covered medications for patients with chronic insomnia. Yet such alternatives exist, are recommended by professional associations and are accessible through private insurance plans.
These include CBT-I, the first-line treatment for insomnia. Comprised of strategies to change sleep habits and perceptions, this intervention improves the sleep of over half of those who undergo it. When CBT-I is insufficient, pharmacological options with a better safety profile than benzodiazepines are available and can be prescribed for insomnia treatment.
However, without adequate reimbursement for these evidence-based interventions, doctors are sometimes forced to prescribe benzodiazepines due to the lack of access to CBT-I and the absence of safe pharmacological alternatives covered by the public system.
As advocates for patient health, we must demand measures to ensure equitable access to evidence-based insomnia treatments for everyone, regardless of socioeconomic status. Therefore, we urge policymakers to prioritize the expansion of public reimbursement programs to include comprehensive insomnia treatment options, including CBT-I and recommended pharmacological treatments for chronic insomnia.
By investing in safe and effective approaches, we can enable those suffering from insomnia to regain control over their sleep and promote a health-care system that prioritizes long-term well-being.
The time to act is now. Let’s work together to finally provide optimal care for insomnia.
